CMS has revised its earlier policy on Medicare Part D payments for drugs used by beneficiaries enrolled in Medicare hospice. In a July 18, 2014 memo, CMS is modifying its March 10, 2014 guidance to Part D sponsors that imposed a prior authorization (PA) requirement for all drugs for hospice beneficiaries in light of operational issues and access concerns. The revised guidance narrows the Part D hospice PA provision to four categories of drugs that the OIG, in consultation with hospice providers, has identified as nearly always covered under the hospice benefit. Specifically, CMS will now “strongly encourage” Part D sponsors to place beneficiary-level PA requirements only on: analgesics, antinauseants (antiemetics), laxatives, and antianxiety drugs (anxiolytics). Part D sponsors are not expected to place hospice PA requirements on other categories of drugs or take special measures beyond normal compliance and utilization review activities to retrospectively review paid claims to determine whether drugs in the other categories were unrelated to the hospice beneficiary’s terminal illness and related conditions or payment recovery.
CMS has made a series of announcements related to the Sunshine Act Open Payments system, including information about the Open Payments review, dispute and correction process that runs from July 14 through August 27, 2014. This period allows physicians and teaching hospitals to review and initiate any disputes they may have regarding the data reported about them by applicable manufacturers and applicable group purchasing organizations. CMS has also extensively updated the Open Payments User Guide, which is intended to provide industry, physicians, and teaching hospitals with a comprehensive understanding of the Open Payments system and reporting requirements.
CMS Announces Plans for Medicare DMEPOS Competitive Bidding Round 2 Recompete and National Mail-Order Recompete
On July 15, 2014, the Centers for Medicare & Medicaid Services (CMS) announced its plans to recompete the supplier contracts awarded in Round 2 of the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program and the National Mail-Order diabetic testing supplies competition, as it is required by statute to do at least every three years. The current contract period expires June 30, 2016; the new contracts will begin on July 1, 2016. For the recompete, CMS is making changes to both the composition of the product categories (including adding new products) and the number of competitive bidding areas (CBAs).
The product categories to be included in the Round 2 Recompete are as follows:Continue Reading...
As recently announced, CMS is conducting what it describes as a “limited demonstration” of an internet-based notice and comment mechanism on internally-generated requests to discontinue Level II HCPCS codes. CMS has just released details regarding the first two HCPCS codes it is proposing to remove under this process:
- A7042 Implanted Pleural Catheter, Each. CMS rationale: the catheter is included in the procedure and therefore a separate code is unnecessary.
- A9586 Florbetapir f18, diagnostic, per study dose, up to 10 millicuries. CMS rationale: HCPCS code A9599 “Radiopharmaceutical, Diagnostic, for beta-amyloid positron emission tomography (pet) imaging, per study dose” adequately describes this product.
CMS will accept public comments on the proposed HCPCS discontinuations until July 21, 2014. Comments should be submitted to firstname.lastname@example.org, and include the following text in the subject line: “COMMENT RE: DISCONTINUATION OF CODE _____.”
HHS has released a report on premiums, tax credits, and health plan choices on the ACA federal Marketplace for plans operating in 2014. In addition, CMS has launched an initiative, dubbed “From Coverage to Care," designed to answer questions consumers may have about their new health coverage under the ACA and to help individuals make the most of their new benefits. The Administration also has announced a number of management changes at CMS designed to strengthen implementation of the ACA going forward, including a Principal Deputy Administrator to oversee ACA Marketplace and other agency operations, a Marketplace Chief Executive Officer, and a Marketplace Chief Technology Officer.
In an effort to “increase program transparency and offer more efficient resolutions to providers” subject to the medical review process, CMS has created the new position of “Provider Relations Coordinator." The Provider Relations Coordinator is intended to improve communication between providers and CMS on medical review process issues. For instance, providers can contact the Provider Relations Coordinator when an auditor is failing to comply with documentation request limits or has a pattern of not issuing review results letters in a timely manner. Providers also can submit recommendations for improving the Recovery Auditor or Medicare Administrative Contractor medical review process to the Provider Relations Coordinator.
On June 18, 2014, CMS announced in a blog posting that it is planning to add a “Five Star” quality rating system to the Hospital Compare, Dialysis Facility Compare, and Home Health Compare websites on Medicare.gov. The agency will start making the new quality ratings available later this year and into early 2015. CMS already maintains star ratings on its Nursing Home Compare and Physician Compare sites.
Earlier this month, CMS released its first annual update to its Medicare inpatient and outpatient hospital charge databases. Specifically, the updated CMS databases include information on 2012 average hospital charges for the 100 most common Medicare inpatient services and 30 most common Medicare outpatient services. The database now includes two years of data, allowing researchers to begin to look at trends. CMS also has released a variety of information on chronic conditions among Medicare fee-for-service (FFS) beneficiaries, including data on prevalence, utilization, and Medicare spending. In addition, the CMS Geographic Variation Dashboards present Medicare FFS per-capita spending at the state and county levels in interactive formats, and a CMS Research Cohort Estimate Tool is intended to help researchers and other stakeholders estimate the number of Medicare beneficiaries with certain demographic profiles or health conditions.
CMS has released the average sales price (ASP) files that will be used to pay for Medicare Part B drugs for the third quarter of 2014. According to CMS, “average drug prices in the market remain relatively stable,” with prices for the top Part B drugs increasing by 1.8% on average.
Is anybody home? Medicare contractors on the prowl for DMEPOS supplier violations of posted business hours and other physical facility standards.
Medicare suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) should be on the alert for enhanced Medicare supplier standard compliance monitoring by CMS, the National Supplier Clearinghouse (NSC), and their agents. Recently, these entities have taken draconian actions to revoke the enrollment of a number of suppliers who failed to be present during indicated hours of operation. Recent Administrative Law Judge (ALJ) decisions have upheld such revocations for technical violation of the Medicare supplier standard, even in the face of extenuating circumstances, reinforcing the need for suppliers to review their practices and policies to ensure full compliance.Continue Reading...
In an email today to stakeholders, CMS announced that it will not be finalizing the ACA Medicaid federal upper payment limits (FUL) for multiple source drugs in July 2014, as previously intended. CMS attributes the change to a delay in providing detailed guidance to the states in preparation for implementation. CMS expects to announce a new finalization date when it releases this subsequent guidance to states.
CMS has announced what it is describing as a “limited demonstration” of an internet-based notice and comment mechanism on requests to discontinue Level II HCPCS codes. The internet-based process would apply to HCPCS discontinuation requests that are generated by CMS based on national program operating needs, and that are not the subject of other notice and comment mechanisms and that are not replaced by other or new codes. CMS contends that this “demonstration” will enhance transparency by providing the public with advance notice and comment opportunity regarding internal decisions to discontinue HCPCS codes. CMS reserves the right to make immediate changes without notice (and take comments afterwards) if it believes there is a national program operating need to do so. The first year of the demonstration will be conducted in the current 2014/2015 HCPCS coding cycle. CMS will publish summaries of internal requests to discontinue permanent level II HCPCS codes by July 1, 2014, and CMS will accept public comments until July 21, 2014.
On May 22, 2014, CMS announced the second round of funding under the State Innovation Models Initiative. This initiative was announced in 2013 to support state design and testing of multi-payer payment and delivery models -- such as accountable care organizations, accountable care communities, patient centered medical homes and bundled payments -- intended to generate savings and improve care for Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries. Under round two, CMS will award as much as $30 million for 15 Model Design cooperative agreements (providing funding and technical assistance as states assess system improvement options) and up to $700 million in funding for 12 state-sponsored Model Test cooperative agreements (intended to assist in implementing developed models).
CMS has announced that it is extending its partial ICD-9-CM and ICD-10 code freeze to reflect enactment of legislation (the Protecting Access to Medicare Act of 2014) that prevents the agency from adopting ICD-10 prior to October 1, 2015. Under the new schedule, on October 1, 2014 there will be only limited code updates to both the ICD-9-CM and ICD-10 code sets to capture new technologies and diseases. On October 1, 2015 (the new compliance date for ICD-10 reporting), there will be only limited updates to ICD-10 code sets to capture new technologies and diagnoses; there will be no updates to ICD-9-CM since it will no longer be used for reporting. On October 1, 2016, regular updates to ICD-10 will begin.
CMS to Implement Ordering/Referring Denial Edits for HHA Certifying Physicians, Effective July 1, 2014
CMS plans to apply “Phase 2” ordering and referring denial edits to certifying physicians of Part A home health agency (HHA) services effective July 1, 2014. These edits, which currently apply only to the attending physician of an HHA, will ensure that the physician that certifies the patient’s eligibility to receive services under the Medicare home health benefit has a valid individual National Provider Identifier (NPI) and are of a specialty type eligible to order and refer the HHA items and services on the claim. The edits will deny the claim when this information is missing or invalid.
On May 9, 2014, CMS announced it is implementing the first phase of its reforms to the Quality Improvement Organization (QIO) Program in an effort to “gain efficiencies, to eliminate any perceived conflicts of interest, and to better address the needs of Medicare beneficiaries.” Under this first phase, CMS has named two Beneficiary and Family-Centered Care (BFCC) QIO contractors -- Livanta LLC and KePRO -- to support case review and monitoring activities on behalf of patients, separate from traditional QIO quality improvement activities. Under the second phase, which is expected to be announced in July, CMS will award contracts to organizations that will focus on data-driven quality initiatives intended to improve patient safety, reduce harm, and improve clinical care and transparency.
CMS has provided additional guidance on its evolving hardship exemptions policy for individuals who had difficulty signing up for a qualified health plan (QHP) through an Affordable Insurance Exchange by the March 31, 2014 deadline. As previously reported, in March CMS announced it had established a “special enrollment period” for individuals who were “in line” but could not complete the enrollment process by March 31 deadline; such individuals were permitted to claim a hardship exemption from the shared responsibility payment for the months prior to the effective date of their coverage. According to a subsequent May 2, 2014 guidance document, CMS believes that “some consumers may not have realized that the relief provided by the guidance above was limited solely to those individuals purchasing QHPs through the Marketplace.” CMS therefore is extending a comparable hardship exemption for all months prior to the effective date of coverage for individuals who obtained minimum essential coverage effective on or before May 1, 2014 outside of the Marketplace, whether the individual is in a state with a federally-facilitated Marketplace or a state-based Marketplace. The May 2 guidance also discusses special enrollment periods for individuals eligible for COBRA, individuals whose individual market plans are renewing outside of open enrollment, and AmeriCorps/VISTA/National Civilian Community Corps members.
CMS has made changes to its Comprehensive ESRD Care (CEC) Initiative to encourage greater participation by both large dialysis organizations (LDOs) and non-LDOs. The goal of the CEC initiative is to improve outcomes for Medicare beneficiaries with ESRD while reducing expenditures by creating financial incentives for dialysis facilities, nephrologists, and other Medicare providers to effectively collaborate on caring for the complex ESRD beneficiary population. In particular, CMS has made changes to the participant owner requirements, the financial risk arrangement, and the financial calculation options. In light of these changes, CMS has reopened the application period; for details on submission dates and additional information, see the CMS web site.
CMS has released guidance in preparation for State Plan Rate Year 2011 (SPRY) Medicaid disproportionate share hospital (DSH) audits and reports due at the end of 2014. By way of background, on December 19, 2008, CMS published a final rule implementing federal DSH reporting and auditing requirements. CMS provided a transition period to allow adequate time for CMS, states, auditors, and hospitals to work cooperatively in developing and refining DSH reporting and auditing techniques while attempting to mitigate fiscal impact realized by states and hospitals. The SPRY 2011 audits and reports are the first that fall outside of the regulatory transition period. As discussed in the guidance, CMS will regard audit findings demonstrating DSH payments that exceed the hospital-specific DSH limits as representing discovery of overpayments to providers. The new guidance addresses various operational issues associated with audit protocols and calculation of costs.
On April 17, 2014, CMS announced that it making inpatient psychiatric facility quality data available as part of the Hospital Compare website. Specifically, CMS is now posting data for the period of October 1, 2012 through March 31, 2013 regarding the following measures: Hours of Physical Restraint Use; Hours of Seclusion Use; Post-Discharge Continuing Care Plan Created; and Post-Discharge Continuing Care Plan Transmitted to Next Level of Care Provider Upon Discharge. Next year, CMS also expects to post data regarding the measures “Patients Discharged on Multiple Antipsychotic Medications” and “Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification.”